Methylene Blue Capsules for Neuroprotection and Brain Health
Once this order form is completed, you have paid for the prescription as well as the capsules. The Doctor will send in the prescription and the capsules will be shipped to you.
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Critical Safety Screening
Please list all prescription and over the counter medications you take. Please write "none" if you do not take any medications or supplements. Please note, if you take SSRI's, consult your prescribing physician before taking methylene blue.
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Have you ever been diagnosed with G6PD (glucose-6-phosphate dehydrogenase) deficiency, or has a member of your immediate family been diagnosed?
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No, never diagnosed and no known family history
Yes, I have been diagnosed
Yes, a family member has been diagnosed but I have not personally been tested
I do not know
Are you currently pregnant, breastfeeding, or actively trying to conceive?
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I am not pregnant, not breastfeeding, and not trying to conceive
I am currently pregnant
I am currently breastfeeding
I am actively trying to conceive
I am not sure
Are you currently taking, or have you taken within the last 14 days, any of the following medications or substances? Please check ALL that apply.
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SSRIs (Prozac, Zoloft, Lexapro, Celexa, Paxil, Viibryd, Trintellix)
SNRIs (Effexor / venlafaxine, Cymbalta / duloxetine, Pristiq, Fetzima, Savella)
Tricyclic antidepressants (Elavil, Pamelor, Tofranil, Anafranil, Norpramin, Sinequan, Surmontil)
MAOIs (Marplan, Nardil, Parnate, Emsam, selegiline)
Bupropion (Wellbutrin, Zyban)
Mirtazapine (Remeron) or Trazodone
Triptans for migraine (Imitrex / sumatriptan, Maxalt, Relpax, Zomig, Frova, Amerge)
Tramadol or tapentadol
Buspirone (BuSpar)
Lithium
Linezolid
Dextromethorphan (in cough syrups)
St. John's Wort
MDMA, LSD, psilocybin, ayahuasca, or other serotonergic substances
None of the above
Are you currently taking any form of ketamine — including troches, nasal spray, infusion, lozenges, or any other formulation — including any prescribed by Dr. David Mahjoubi at NutraBrain Clinic or Dr. David Wellness?
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No
Yes
Medical History
Do you have, or have you been diagnosed with, any of the following kidney or liver conditions? Check all that apply.
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Do you have any of the following heart or blood pressure conditions? Check all that apply.
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Do you have any of the following blood conditions? Check all that apply.
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Do you have any known drug allergies or sensitivities, including to dyes, sulfites, or methylene blue itself? If yes, please describe.
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. NATURE OF THIS DOCUMENTThis is a legally binding informed consent for the off-label use of compounded methylene blue capsules. Please read every section carefully before signing. Your signature at the end indicates that you have read, understood, and agreed to every section. If anything is unclear, stop and contact our office at (818) 570-1640 or dr@nutrabrainclinic.com before signing.2. PURPOSE OF TREATMENT AND OFF-LABEL DISCLOSUREI, the undersigned, hereby consent to receive compounded methylene blue capsules prescribed by David Mahjoubi, MD through NutraBrain Clinic, Inc., doing business as Dr. David Wellness, ordered through the drdavidwellness.com website.I understand and acknowledge the following:Methylene blue (methylthioninium chloride) is FDA-approved by injection only, for the treatment of methemoglobinemia and a small number of other narrow medical uses.The use of methylene blue capsules for cognitive function, energy, mitochondrial support, mood, or any wellness purpose is considered off-label. This means it is not an FDA-approved use of the drug.Off-label prescription by a licensed physician is legal in the United States but signifies that the FDA has not formally evaluated this specific use for safety or efficacy.The product I am receiving is a pharmaceutical-grade compounded medication prepared by a U.S.-licensed compounding pharmacy. It is not a dietary supplement, not industrial-grade methylene blue (such as products sold for aquarium or laboratory use), and not a manufactured product subject to FDA Current Good Manufacturing Practice (cGMP).I will not substitute or supplement my prescription with any non-prescription methylene blue product purchased from another source. I understand that some methylene blue products sold online are industrial grade and unsafe for human consumption.3. NATURE OF THE TELEHEALTH RELATIONSHIPI acknowledge and understand:This is a telehealth prescribing relationship. Dr. Mahjoubi has not physically examined me and may evaluate me only by video, telephone, secure messaging, and questionnaire.Telehealth has inherent limitations compared with in-person care. A telehealth provider cannot perform a physical examination, cannot directly observe me for subtle clinical signs, and depends on the accuracy and completeness of the information I provide.I am responsible for accurately disclosing my full medical history, every medication I take (prescription, over-the-counter, herbal, and supplement), and any change in those medications during the course of treatment.Dr. Mahjoubi prescribes methylene blue only in U.S. states in which he is licensed. By providing my state of residence and signing this form, I confirm that I currently reside in a state where Dr. Mahjoubi is licensed to prescribe.I will continue to see my primary care physician and any specialists for my non-related medical care. Methylene blue treatment is not a substitute for primary care, mental health care, or any other ongoing medical relationship.4. PRE-TREATMENT SCREENING AND TESTINGI understand that before methylene blue is prescribed, I am responsible for completing the following:G6PD (Glucose-6-Phosphate Dehydrogenase) status: Methylene blue can cause serious hemolytic anemia in patients with G6PD deficiency. I have either (a) provided documentation of prior G6PD testing showing normal activity, OR (b) been informed of the option to obtain G6PD testing and have declined, accepting full responsibility for that decision. Initial the option that applies:___ I have provided documentation of prior G6PD testing showing normal activity.___ I have been informed and decline G6PD testing, and I accept full responsibility for this decision.I have disclosed any history of methemoglobinemia, hemolytic anemia, glucose-6-phosphate dehydrogenase deficiency, or any other red blood cell disorder.I have disclosed any history of kidney disease, liver disease, or severe hepatic impairment.I have disclosed any psychiatric history, including any current or past use of antidepressants, antipsychotics, or mood stabilizers.5. ABSOLUTE CONTRAINDICATIONS — I CONFIRM I DO NOT HAVE ANY OF THE FOLLOWINGI confirm I am NOT currently and do not have a history of:G6PD deficiency (without documented clearance from a physician)Severe renal impairment (severely reduced kidney function)Severe hepatic impairment (severely reduced liver function)Currently pregnant, planning to become pregnant during treatment, or breastfeedingCurrently using monoamine oxidase inhibitor (MAOI) antidepressants including isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), or selegiline (Emsam)Currently using linezolid (Zyvox) or other antibacterial MAOIsUnder the age of 18If any of the above applies, I will not take methylene blue and will notify Dr. Mahjoubi immediately.6. SERIOUS DRUG INTERACTIONSI understand that methylene blue is a reversible monoamine oxidase inhibitor (MAOI) and can cause serotonin syndrome — a potentially life-threatening condition — when combined with medications and supplements that increase serotonin levels. I have disclosed all of my current medications and supplements. I will not start any of the following without discussing it with Dr. Mahjoubi first:Antidepressants and psychiatric medications (incomplete but representative list)SSRIs: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva, Brisdelle), sertraline (Zoloft), fluvoxamine (Luvox), vilazodone (Viibryd), vortioxetine (Trintellix)SNRIs: duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), levomilnacipran (Fetzima), milnacipran (Savella)Tricyclic antidepressants (TCAs): amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), trimipramine (Surmontil)MAOIs: isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Emsam)Other antidepressants: bupropion (Wellbutrin), mirtazapine (Remeron), trazodone, nefazodoneAtypical antipsychotics with serotonergic activity: olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, lurasidone, clozapineLithiumBuspirone (Buspar)Esketamine (Spravato) — note that conventional ketamine treatment is generally compatible; please discuss with Dr. MahjoubiPain and migraine medicationsTramadol (Ultram)Meperidine (Demerol)Fentanyl (significant risk)Methadone (significant risk)Triptans: sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax), zolmitriptan (Zomig), almotriptan (Axert), naratriptan (Amerge), frovatriptan (Frova)Cyclobenzaprine (Flexeril)Stimulants and ADHD medicationsAmphetamines: Adderall, Vyvanse, DexedrineMethylphenidate: Ritalin, Concerta, FocalinCough, cold, and antinausea medicationsDextromethorphan (DM): common in Robitussin DM, NyQuil, and many over-the-counter cough preparationsOndansetron (Zofran) and other 5-HT3 antagonists: granisetron, palonosetronMetoclopramide (Reglan)AntibioticsLinezolid (Zyvox) — strict contraindicationOther MAOI antibioticsHerbal supplements and over-the-counterSt. John's Wort5-HTP (5-hydroxytryptophan)L-tryptophan supplementsSAM-e (S-adenosyl-L-methionine)High-dose ginsengMDMA, cocaine, or any recreational drug with serotonergic activity — methylene blue must not be combined with these substancesI confirm that I have disclosed all of my current medications and supplements to Dr. Mahjoubi and have been advised of any interactions specific to my regimen. I agree to immediately notify Dr. Mahjoubi if any new medication or supplement is added during my treatment.7. POTENTIAL SIDE EFFECTSI understand methylene blue can cause side effects, including but not limited to:Common (often mild and resolve on their own)Nausea, gastrointestinal discomfort, mild diarrheaHeadacheDizziness or lightheadednessBluish-green discoloration of urine and sometimes saliva, sweat, or stool — this is harmless and expectedTemporary blue tint to the tongue or mouthMild fatigue or stimulation, depending on individual responseSkin sensitivity to lightLess common but potentially seriousHemolytic anemia (breakdown of red blood cells), particularly in those with G6PD deficiency. Signs include unusual fatigue, jaundice (yellowing of skin or eyes), dark or red-tinged urine, rapid heart rate, and shortness of breath.Methemoglobinemia at high doses (paradoxical — methylene blue treats this at lower doses but can cause it at higher doses)Serotonin syndrome (see Section 6 — drug interactions). Signs include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, sweating, shivering, muscle rigidity, tremor, fever, vomiting, and diarrhea. Serotonin syndrome can be fatal and requires immediate emergency care.Allergic reactions: rash, hives, swelling of face, tongue, or throat, severe dizziness, difficulty breathingCardiovascular: chest pain, palpitations, irregular heartbeatNeurologic/psychiatric: confusion, mood changes, agitation, restlessness, mania (particularly in patients with bipolar disorder), tremorI understand these side effects can range from mild and self-limited to medically serious. I agree to stop taking methylene blue and seek immediate medical attention (call 911 or go to the nearest emergency room) if I experience any of the serious side effects listed above.8. WHAT TO DO IF YOU SUSPECT SEROTONIN SYNDROME OR AN ALLERGIC REACTIONI have read and will follow this emergency action plan:STOP taking methylene blue immediately.Call 911 or go to the nearest emergency room if I experience any combination of: high fever, severe agitation, confusion, rapid heart rate, muscle stiffness or twitching, severe tremor, sweating, shivering, dilated pupils, or loss of consciousness.Tell the emergency provider that I have been taking methylene blue and show them this consent form or a list of my medications.Call 911 immediately if I experience: difficulty breathing, swelling of the face, lips, tongue, or throat, severe chest pain, irregular heartbeat, or fainting.After receiving emergency care, notify Dr. Mahjoubi's office at (818) 570-1640 or dr@nutrabrainclinic.com as soon as I am able.9. DOSING, ADMINISTRATION, AND STORAGEI agree to:Take methylene blue only as prescribed by Dr. Mahjoubi. I will not exceed the prescribed dose or take it more frequently than prescribed.Not share my medication with any other person, including family members. Sharing prescription medications is illegal and unsafe.Store methylene blue capsules out of reach of children and pets. Methylene blue can be dangerous if taken in large amounts.Take methylene blue with water as directed. Note that it may stain teeth, tongue, mouth, and clothing — using a straw can help.Discontinue use and contact the prescriber if I experience side effects I am unsure about.Avoid prolonged sun exposure during treatment, as methylene blue may increase photosensitivity.Inform any other healthcare provider (dentist, surgeon, anesthesiologist, pharmacist) that I am taking methylene blue before any procedure, surgery, or new prescription.10. ALTERNATIVES TO TREATMENTI understand that I am under no obligation to take methylene blue. Alternatives may include:No treatmentLifestyle interventions (sleep, exercise, nutrition, stress management)FDA-approved medications for any underlying conditions I may haveEvaluation and treatment by a primary care physician, psychiatrist, neurologist, or other specialistOther evidence-based interventions appropriate for my specific medical situationI have had the opportunity to discuss these alternatives with Dr. Mahjoubi and have weighed them against the option of starting methylene blue.11. NO GUARANTEE OF BENEFITI understand and acknowledge:Dr. David Mahjoubi, MD, NutraBrain Clinic, Inc., and Dr. David Wellness make no guarantee, expressed or implied, that I will experience any specific benefit from methylene blue capsules.Individual response to methylene blue varies widely. Some patients report benefits; others report no perceptible effect.Marketing claims about methylene blue's effects on cognition, energy, mitochondrial function, and aging are based on emerging research and have not been confirmed by the FDA for the off-label uses I am pursuing.I have not been promised any specific therapeutic outcome.12. PATIENT RESPONSIBILITIES AND ATTESTATIONSBy signing this form, I attest that:I have provided complete, accurate, and truthful information about my medical history, current medications, supplements, and lifestyle.I will promptly notify Dr. Mahjoubi of any change in my health status, any new medication or supplement, or any concerning symptom during the course of treatment.I will not misrepresent my age, state of residence, identity, or medical condition.I have provided my own legal identification and authorize Dr. Mahjoubi to verify it.I will use this prescription only for myself, in the manner directed.I understand that this medication is intended for my personal use and will not be resold, redistributed, or shared.I have read and reviewed the drdavidwellness.com Privacy Policy and Terms of Service.13. VOLUNTARY CONSENT AND RIGHT TO WITHDRAWI confirm that:I have read this entire form, understand its contents, and have had every question I wished to ask answered to my satisfaction.My consent is given voluntarily, without coercion or pressure.I have the right to withdraw my consent and discontinue methylene blue treatment at any time, without penalty other than non-refundability of medication already shipped or services already rendered.I understand I may contact Dr. Mahjoubi's office at any time at (818) 570-1640 or dr@nutrabrainclinic.com to discuss withdrawing or modifying treatment.14. RETURN AND REFUND POLICYI understand that methylene blue capsules are a custom-compounded prescription medication and therefore:Once dispensed and shipped, the product cannot be returned or refunded for any reason, in accordance with federal and state regulations governing the return of prescription medications.Consultation fees, if any, are non-refundable once the consultation has occurred.If I receive a damaged or incorrect order, I will notify Dr. David Wellness within 7 days of receipt for resolution.15. ADVERSE EVENT REPORTINGI understand that:Dr. Mahjoubi may report any adverse drug event related to my treatment to the FDA MedWatch program (FDA's adverse event reporting system) and to the compounding pharmacy, as required or permitted by law.I may also report adverse events directly to the FDA at www.fda.gov/medwatch or 1-800-FDA-1088.Reporting an adverse event does not waive any of my rights and is part of standard medical practice.16. PRIVACY, HIPAA, AND COMMUNICATIONSI acknowledge that:NutraBrain Clinic, Inc. d/b/a Dr. David Wellness operates in accordance with HIPAA. The Notice of Privacy Practices is available at drdavidwellness.com.I have been offered the opportunity to review the Notice of Privacy Practices.I authorize Dr. Mahjoubi and his designated staff to communicate with me by email, secure portal, telephone, and text message regarding my care.I understand that email and text communications carry inherent privacy risks and I accept those risks by authorizing them.I authorize Dr. Mahjoubi to share information with my primary care physician and any other physicians I designate.17. GOVERNING LAWI understand that this consent and any dispute arising from my treatment with methylene blue from Dr. David Wellness is governed by the laws of the State of California without regard to its conflict of laws principles, and that any disputes will be resolved in the appropriate courts of California, except where applicable law requires otherwise (for example, for medical board complaints, which are governed by the medical board of the relevant state).18. FINAL ACKNOWLEDGMENT AND SIGNATUREBy signing below, I confirm that:I have read and understood every section of this informed consent form.I have had the opportunity to ask questions and have received satisfactory answers, or have declined the opportunity to ask further questions.I am at least 18 years of age, of sound mind, and legally competent to give consent.I am providing this consent freely and voluntarily.I have received or been offered a copy of this form for my records..
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Patient Acknowledgments — Please read and check each box to indicate your agreement
I confirm that the information I have provided in this form is true, complete, and accurate to the best of my knowledge.
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I confirm that the information I have provided in this form is true, complete, and accurate to the best of my knowledge.
I understand that methylene blue is being prescribed off-label — meaning it is not FDA-approved for the cognitive, neuroprotective, or energy-related uses being requested — and that the long-term safety of these uses is not fully established.
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I understand that methylene blue is being prescribed off-label — meaning it is not FDA-approved for the cognitive, neuroprotective, or energy-related uses being requested — and that the long-term safety of these uses is not fully established.
I understand that no in-person physical examination is being performed as part of this prescription, and that Dr. David Mahjoubi is relying entirely on the accuracy of my answers in this form.
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I understand that no in-person physical examination is being performed as part of this prescription, and that Dr. David Mahjoubi is relying entirely on the accuracy of my answers in this form.
I understand that I have the option of being evaluated by a physician in person and have chosen this telehealth pathway voluntarily.
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I understand that I have the option of being evaluated by a physician in person and have chosen this telehealth pathway voluntarily.
I understand that no specific therapeutic benefit is guaranteed and that individual results vary.
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I understand that no specific therapeutic benefit is guaranteed and that individual results vary.
I agree not to exceed the dose prescribed and to discontinue immediately and seek medical attention if I experience any of: severe headache, confusion, agitation, rapid heartbeat, tremor, sweating, blue or green discoloration of skin or urine accompanied by shortness of breath, sudden vision changes, or any allergic reaction.
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I agree not to exceed the dose prescribed and to discontinue immediately and seek medical attention if I experience any of: severe headache, confusion, agitation, rapid heartbeat, tremor, sweating, blue or green discoloration of skin or urine accompanied by shortness of breath, sudden vision changes, or any allergic reaction.
I agree to inform my primary care provider that I am taking compounded methylene blue.
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I agree to inform my primary care provider that I am taking compounded methylene blue.
I will not share this medication with any other person, and I will store it out of reach of children and pets.
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I will not share this medication with any other person, and I will store it out of reach of children and pets.
I understand that if I am scheduled for surgery or anesthesia within 14 days, I must inform the anesthesiologist that I have taken methylene blue, because it can interfere with pulse oximetry and can interact with anesthetic agents.
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I understand that if I am scheduled for surgery or anesthesia within 14 days, I must inform the anesthesiologist that I have taken methylene blue, because it can interfere with pulse oximetry and can interact with anesthetic agents.
I understand that compounded medications are not FDA-approved as finished products and may not be returned once the seal is broken, except in the case of damage or shipping error.
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I understand that compounded medications are not FDA-approved as finished products and may not be returned once the seal is broken, except in the case of damage or shipping error.
I agree to follow up with Dr. David Mahjoubi if I experience any unexpected side effect or change in my health while taking methylene blue.
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I agree to follow up with Dr. David Mahjoubi if I experience any unexpected side effect or change in my health while taking methylene blue.
Do you take a Serotonin Reuptake Inhibitor, or SSRI? Examples include Prozac, Zoloft, Celexa, Lexapro, Paxil, and Viibryd? If the answer is yes, please consult with your prescribing phsycian before purchasing methylene blue.
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Methylene Blue - 30 capsules
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